Implementing a new Hospital at Home program would likely take an organization approximately one year from conception to operation. A new program would need to hire staff, adapt and integrate Hospital at Home processes clinical and administrative processes into the mainstream of organization, and establish a process for arranging to bring services, equipment and providers into patient homes.

Working as a Hospital at Home nurse is a demanding job that requires specific skills and qualities. Leaders of the program at the Portland VA Medical Center look for the following skills and qualities in RNs hired to work in the model.

• Good patient assessment skills
• Experience working in home health care or in the home
• Flexibility
• Thoroughness
• Good relationships with doctors
• Assertiveness
• Ability to follow through
• High degree of professionalism and teamwork

The Hospital at Home national organization is in the process of developing training tools to help encourage dissemination of the model. Please check the organization’s website for available tools.

The typical process for admitting a new patient into the Hospital at Home occurs in the emergency department, when an ED physician and/or nurse identify a patient who meets the basic eligibility criteria for the program. The ED physician then consults with a Hospital at Home physician on the phone or in person to determine if the patient meets criteria for Hospital at Home care.

Medical treatments are initiated in the emergency department, as would be the case for any patient being admitted to the traditional acute hospital. In addition, the Hospital at Home physician will write a set of Hospital at Home admission orders. The admission is tightly coordinated with and by RN Coordinator, who will oversee the delivery of all necessary home equipment, supplies and medications.

Portland VA Medical Center implemented Hospital at Home, initially as part of a national demonstration study. Following the study, Portland VA adapted the model to better serve its need. The revised model, Program at Home, extended the types of patients seen to include any patients over the age of 18 with the original conditions (COPD, CHF, pneumonia and cellulitis). In addition, Program at Home includes a transfer component. Much in the way that patients are transferred within hospitals, for example from an intensive care unit to a medical/surgical unit, patients are transferred from a medical/surgical unit bed to Program at Home care to complete their acute hospital care; over half of Program at Home patients are transfer patients.

In Portland’s Program at Home, the physician typically visits transfer patients once, but the physician continues to manage the daily plan of care. The RN visits the patient at home once a day and has the flexibility to increase the number of visits when needed. Patients are only admitted to Program at Home until 4:30 pm to ensure that necessary resources can be coordinated for the patient’s home that day. Patients admitted directly from the emergency room to Program at Home usually receive more intensive services.

Kaleida Health, a Medicare managed care health system in New York, also implemented Hospital at Home as part of a national demonstration study in 2001.

In addition, the VA Medical Center New Orleans is implementing Hospital at Home as a way to continue to provide VA hospital-level services to New Orleans veterans while the hospital is closed (due to damage sustained from Hurricane Katrina).

Finally, several large Medicare managed care organizations are developing plans to implement Hospital at Home programs.

The John A. Hartford Foundation has provided some for the Hopkins team to provide technical assistance to organizations interested in replicating the Hospital at Home model.

The Hospital at Home model creates a financing challenge in non-capitated health care systems, as US payers do not offer sufficient reimbursement for acute home-based services. Champions of the model have applied for a waiver as a Medicare demonstration project, which could help speed the development of appropriate reimbursement and the eventual spread of the model.

Despite the reimbursement challenges, the model could help hospitals facing shortages of acute care beds.

An additional challenge of the model is the difficulty in serving patients across a broad geography. Successful implementations of this model have limited the geography to a 20 or 30-mile radius from the hospital.